Evidence Brief: Effect of Geriatricians on Outcomes of Inpatient and Outpatient Care

Projections are that 43% of all Veterans older than 65 will be enrolled in VA by 2013, up from 31% in 2003. Moreover, 20% of Veterans older than 85 years of age received VA healthcare in 2003, and this is expected to rise to 51% by 2013. Older Veterans are more likely to have multiple chronic illnesses and age-related disability, take multiple medications, and to get their healthcare from several clinicians. All of these factors increase the chances for miscommunication and fragmented care that can result in negative consequences for older Veterans, such as adverse drug events or reduced function.

Recently, investigators at the VA Evidence-Based Synthesis Program located in Portland, Oregon summarized available research literature — published from 1985 through March 2012 — on the effects of including geriatricians in inpatient and outpatient care. This evidence brief was produced in response to a time-sensitive request from the Office of Geriatrics and Extended Care and the Healthcare Delivery Committee of VA's National Leadership Council. Evidence briefs differ from a full systematic review in several ways. The scope of work is more narrowly defined: briefs present a concise, high-level review of scientific literature drawing from existing high-quality reviews and are conducted within one to three months.

Evidence on the Effect of Geriatricians on Inpatient Care
Data were summarized from five recent, good-quality systematic reviews of inpatient geriatric care involving geriatricians. This was supplemented with the results from four fair- or good-quality randomized trials, and one fair-quality observational study of inpatient care that were not included in these systematic reviews. The overall findings are:

• Patients receiving care in special geriatric units that are staffed by a team including a geriatrician have better function at discharge and are more likely to be discharged to home than patients receiving standard hospital care.
• Inpatient rehabilitation including a geriatrician resulted in lower nursing home admissions, improved function and lower mortality at follow-up (range 3-12 months) compared to usual care.
• Evidence about the effect of inpatient geriatric intervention on hospital readmission, length of stay, emergency visits, and outpatient visits is insufficient to draw conclusions.
• Neither inpatient geriatric units nor inpatient geriatric teams had lower patient mortality rates when compared with usual care.
• There is insufficient evidence to allow any conclusion about whether models of care that use geriatricians as inpatient consultants are effective.
• Geriatricians in special teams that conduct Comprehensive Geriatric Assessments and advice on patient care across hospital units (floating teams) do not improve patient outcomes.
• For all types of interventions involving geriatricians in inpatient care:
  • Detailed examinations of the impact of different components of the intervention, including the specific contribution of the geriatrician, are difficult to isolate from published studies.
  • More research is needed about what components of specific types of interventions are most likely to improve patient outcomes.

Three good-quality systematic reviews attempted to identify components of care that are essential for positive outcomes. These attempts found either no difference (e.g., outcomes were not better in studies where geriatric care was targeted to patients based on criteria other than age alone) or reported that the impact of different components of the intervention, including the specific contribution of the geriatrician, were difficult to isolate from published descriptions of the studies.

Evidence on the Effect of Geriatricians on Outpatient Care
Five good-quality systematic reviews about models of geriatric outpatient care, and 11 fair- or good-quality randomized trials and observational studies not covered by these reviews were identified and summarized. The evidence from this research is:

• Geriatricians in teams and as consultants had mixed results in terms of impact on function, living at home and health services utilization.
• Interventions in which geriatricians have direct patient contact are more likely to result in better outcomes than interventions where the interaction is limited to supporting other clinicians.
• Geriatricians as primary care providers provide more effective medication management than other clinicians.
• The evidence does not show that outpatient care involving geriatricians reduced mortality compared to usual care.

Limitations
Geriatrician care is often a component of complex care models and these models, not their components, are most often the subject of research. This made isolating the contribution of the geriatricians to the reported outcomes difficult. Additionally, there is no consensus on what represents best practice for evidence briefs or rapid reviews. While the investigators conducted an extensive bibliographic search, they limited the number of databases searched, and did not search extensively for grey literature or research in progress. They used existing systematic reviews as the foundation for their evidence summaries, and did not re-review all of the studies included in these systematic reviews.

A Cyberseminar session on this ESP Report was held on Wednesday, March 20, 2013 from 11:00am to 12:15pm (ET). View archive here.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Reference

Totten A, Carson S, Peterson K, Low A, Christensen V, Tiwari A. Evidence Brief: Effect of geriatricians on outcomes of inpatient and outpatient care, VA-ESP Project #09-199; 2012.

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Read past HSR&D Management e-Briefs on the HSR&D website.

This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

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